Download Heme Study Guide

Lecture 1: Structure and Function of the Hematopoietic System

Myeloid Elements hematopoiesis
1. Myeloblast
2. Promyelocyte
3. Myelocyte
4. Metamyelocyte
5. Band Form
6. Neutrophils, eosinophils, basophils
o Monocytes (indented nucleus)

Erythroid Elements hematopoiesis
1. Pronormoblast
2. Basophilic normoblast
3. Polychromatic normoblast
4. Orthostatic normoblast
5. Reticulocyte
6. Erythrocyte

Megakaryocytes
o Polyploid (DNA replication without cell division)
o Forms platelets

Bone marrow biopsy
o Cellularity
o ME:EE = 3:1
o Fe? Sideroblasts?
o Megakaryocytes (1-2/hpf)
o Scant reticulin (around vessels, trabeculae)
o Lymphocytes, plasma cells
o Tumors? Granulomas?

Spleen
o White pulp surrounds central arteriole – immune rxn to antigens
 Lymphoid tissue
 T cell sheath
 B cell compartment with 2° follicles
o Red pulp; bulk of the spleen – filters blood, destroys bad RBCs
 Sinus compartment – lined by fenestrated endothelium and discontinuous
bm
 Splenic cords of Billroth – between sinuses; macrophages
 Marginal zone – between red and white pulp; filtering function of spleen

Lymph nodes
o Cortex: germinal centers (B Cell maturation, CD20+, plasma cells)
o Paracortex: T cells
o Sinuses are lined by histiocytes; lymph enters via afferents and leaves via
efferents. Histiocytes phagocytose and filter the lymph
o Increase in size is generally reactive (80% follicular hyperplasia. + Granulomas,
toxo, cat scratch disease)
o 1° follicle = no germinal center; 2° = germinal center
o Fetal nodes = no antigen exposure, no 2° follicles

Assessing clonality
o B Cells: κ or λ of Ig produced
o T Cells: TCR, genes; no good surface Ag
Lecture 2: Clinical Disorders of Iron Metabolism

Iron Balance
o RBCs catabolized → Fe released → transferrin picks up → circulation → bone
marrow → Fe endocytosis → DCT1 → Iron to mitochondria → Heme
o Transferrin drops Fe off at the cell membrane and is recycled back to the
circulation
o Ferritin can take up Fe2+ and oxidize it to Fe3+ for storage
 Fe deficiency → ↑ DCT1 and ↓ Ferritin

Iron Absorption
o Throughout small intestine, maximal in the duodenum
o Non-heme Fe → Fe3+ → reductase → Fe2+ → DMT1 → Enterocyte →
Ferroportin → Basal side → Fe2+ → Oxidase → Fe3+ → ferritin transport
o Heme Fe → HCP1 → Enterocyte → Ferroportin, etc.
o Liver → hepcidin → degrades ferroportin → ↓ Fe absorption

Iron Deficiency
o Hypochromic Microcytic Anemia;
 ↑ Transferrin
 ↓ Fe
 ↑ TIBC
 ↓ Ferritin
o Koilonychia (spoon nails), mucosal atrophy of tongue and stomach, alopecia,
pica, intestional malabsorption
o Usually from blood loss
o GI tract can increase Fe absorption with increased blood loss. If this isn’t enough,
the liver can mobilize its stores (stage 1 – normal Hb mass, normochromic,
normocytic cells but ↓ stores)
o If stores become depleted, cells become microcytic. MCHC normal and cells are
normochromic (stage 2)
o With progressive loss, the Hb falls faster than the MCV, so the MCHC decreases.
(stage 3)
o With progressive loss, the RBCs become fragmented and severe poikilocytosis
(abnormal RBCs). Hypochromic, microcytic. ↓ RBC survival 2° to ↑ hemolysis
(stage 4)
Anemia of Chronic Inflammatory Diseases
o Microcytic and occasionally hypochromic
 ↓ Fe
 ↓ TIBC
 ↑ Ferritin
o Abundant stainable iron in macrophages
o Decreased iron absorption
o Defect in the release of Fe from macrophages during their catabolism
o IL6 increases hepcidin synthesis and inhibits ferroportin and, thus, the release of
Fe from cells and the absorption of Fe in the intestine

o ↓ erythropoietin response/sensitivity

Sideroblastic/Iron loading Anemia
o Hyperchromic
 ↑ Fe
 NL TIBC
 ↑ Ferritin
o Sideroblast – non-heme iron in cytoplasm, usually in mitochondria surrounding
the nucleus
o Defect in heme synthesis, in any of the 7 steps from Gly + Succinyl CoA →
Heme
o Congenital
 Thalassemia - ↓ in globin chain synthesis, excess heme accumulates and
inhibits ALA synthetase
 Familial/Sex-linked – Mut in ALA synthetase plus ↑ absorption of GI
heme; accumulations in organs
 Lead poisoning – inhibits ALA synthetase, ALA dehydrase, heme
synthetase. Detect lead in blood
 Alcoholism inhibits ALA synthetase. Responds to Pyridoxal-5-Pi
 INH and cycloserine antagonize pyridoxine

Hereditary Hemochromatosis
o Autosomal recessive disorder that causes ↑ GI iron absorption (no active method
to excrete iron)
 ↑ Transferrin
 ↑ Ferritin (>300 mg/ml)
o Iron accumulates in organs
o HFE decreases hepcidin, which leads to no ferroportin degradation and ↑ GI
absorption
o Tx: weekly phlebotomy to decrease stores, then every 3-4 months
Fe/TIBC
Ferritin
Fe deficiency
↓/↑
↓
Chronic Disease
↓/↓
↑
Sideroblastic
↑/NL
↑
Lecture 3: Megaloblastic Anemia



Defective and slowed DNA synthesis
Vit B12 and Folate are coenzymes in DNA synthesis (not RNA)
o Deficiencies → DNA replication and cellular division are slowed, while
cytoplasm (RNA and protein) synthesis is normal
↑ amount of DNA/megaloblastic cell
o ↑ size of nucleus
o ↑ DNA content
o Large cytoplasm (normal synthesis here)
o Biochemically defective DNA synthesis

Bone Marrow
o Slowing of the S phase
o ↑ intramedullary cell death
o Hyperplastic marrow, appears to be wildly proliferating
o ↑ Megaloblastic erythroid precursors
 ↑ nucleus/cytoplasm ratio
 Basophilic cytoplasm
 Prominent nucleoli
o Nuclear/cytoplasmic dissociation in erythroid and granulocytic precursors
o Megakaryocytes have ↑ nuclei and giant platelets

Peripheral Blood
o Pancytopenia
o ↑ variation in size and shape of RBCs
 Normochromic
 Macrocytic
 ↑ MCV
 If comorbid with thalassemia trait or severe Fe deficiency, MCV
will not be elevated
 Macroovalocytes (oval macrocytes) mixed with tear drops
o ↓ reticulocytes
o ↑ nucleated RBCs
o ↓ platelets
o Hypersegmented polys
o ↑ auto-hemolysis

Other lab findings
o ↑ serum Iron
o Saturated transferrin
o ↑ LDH
o ↓ RBC survival
o ↓ Haptoglobin (binds free Hb released from RBCs to prevent oxidation)
o ↑ methemalbumin

PE
o
o
o
o
o
o
o

Pallor
Fatigue
SOB
Icterus
Hepatosplenomegaly
Red, beefy, depapillated tongue
+ B12 deficiency
 Peripheral neuropathy
 Ataxia
 Parasthesia
Pathogenesis
o Vit B12
 Corin ring with Cobalt
 Absorption
 Parietal cells secrete Intrinsic Factor and allows B12 to be
absorbed in the terminal ileum
 Carried by transcobalamin
 Inadequate intake (rare)
 Body stores last for years
 Malabsorption
 Lack of intrinsic factor
o Congenital defect in kids
o Pernicious anemia, autoimmune in adults
 Atrophic gastritis
 Abs to IF, parietal cells
o Bacterial overgrowth/fish tapeworm compete for B12
utilization and prevent absorption
o Ileal disease or resection
o Gasterctomy
o Chronic PPIs
o Folate
 No neurological symptoms
 Absorption in the proximal jejunum
 Causes
 Dietary deficiency common cause of megaloblastic anemia
 Anticonvulsants, barbiturates, metformin, alcohol
 Dialysis
o Neurologic changes
 Only present in B12 deficiency; inability to synthesize myelin
 Begin in the peripheral nerves and progress to involve the posterior and
lateral columns
 Variable ∆ms
 ↑ serum methyl malonic acid and homocysteine
o Vascular disease
 ↑ homocysteine ↑ risk for thrombosis and premature CV disease

Dx
o
o
o
o
o

Coalamin assay (α to B12)
Folate assay
Stomach pH (neutral if pernicious)
Anti-IF/parietal cells Abs (pernicious)
Schillings test (for B12)
Tx
o IV B12 QD x 7days then Q30 days
o ↑ dose po cobalamin
o po Folate (will not tx neurological sx)
Lecture 4: Hemolytic Anemia

Findings
o ↓ RBC survival
o ↑ Bilirubin
o ↑ LDH
o ↓ Haptoglobin
o ↑ Reticulocytes (if marrow is normal)

Causes
o Inherited
 Membrane Diseases
 Hereditary spherocytosis
 Hereditary elliptocytosis/pyropoikilocytosis
 Enzyme Disorders (leads to methemoglobinemia)
 G6PD deficiency
 Pyruvate kinase deficiency
 Pyrimidine 5’ nucleotidase
 Acquired
 Liver/Renal dysfunction

RBC membrane
o Outer lipid bilayer with proteins
 Phospholipids + cholesterol (exchanges with plasma cholesterol)
o Underlying cytoskeleton
 Spectrin
o Absence of spectrin or other membrane proteins → bilayer destabilization →
budding vesicles → pass through spleen/liver → ↑ vesicle loss → ↓ SA/vol ratio
→ RBC becomes rigid and spherocytic → ↑ splenic trapping and hemolysis

Hereditary Spherocytosis
o Spherical RBCs on peripheral smear
o ↑ in Northern Europe
o ↑ Hemolysis
o ↑ MCHC (only thing that does this!)
o Gallstones, hemolytic/aplastic crises, megaloblastic crisis, CHF, jaundice, anemia,
splenomegaly
o ↑ osmotic fragility (early lysis with hypotonic solutions)
o Defects in ankyrin, band 3, spectrin, protein 4.2
o Tx
 Splenectomy with prophylaxis for pneumococcus, H. flu, and N.
meningitides

Hereditary Elliptocytosis/Pyropoikilocytosis
o Ellipitical, cigar-shaped RBCs on peripheral smear (~ to thermal burn)
o ↑ in African/Mediterranean descent + some malaria resistance
o Mechanical weakness of the cytoskeleton due to defects in proteins
o Anemia
o Abnormal osmotic fragility test
o Tx
 Rarely necessary, but splenectomy can be helpful

Acquired membrane defects
o Spur cell
 From liver disease
 Abnormal lipoproteins
 ↑ free cholesterol and inserted on RBC membrane, expanding the bilayer,
↑ surface area and targeting of the RBC
 Splenic trapping, hemolysis
o Burr cell
 From renal insufficiency
 Uniform projections
 Normal cholesterol content

Enzyme abnormalities
o Maintenance of the RBC membrane
 Glycolytic (Emden-Meyerhof/anaerobic) pathway
 Aerobic (Hexose monophosphate) pathway
o Pyruvate kinase deficiency
 In glycolysis, PK converts phosphoenol pyruvate to lactate, creating ATP
 Deficiency leads to ↓ ATP and ↑ hemolysis from birth (variable)
 Chronic anemia, jaundice, gallstones, moderate splenomegaly
o G6PD Deficiency
 G6PD catalyzes the first step in the generation of NADPH, used to reduce
glutathione and therefore, maintain Hb in the soluble form
 Deficiency leads to ↑ oxidating agents, insoluble Hb, deposits as
Heinz bodies and ↑ hemolysis
 Short acting hemolysis
 Heinz bodies
 Some malaria protection
 Dx
 Acute hemolysis who may have ingested an oxidant drug
o Methylene blue
o Fava beans
o Primaquine
o Naphthalene
o Pyrimidine 5’ nucleotidase deficiency
 Important in cleaving nucleotides → nucleosides (-sides can leave the cell,
unlike –tides)
 Pyrimidine nucleotides can compete with ADP/ATP in the
glycolytic pathway
 This leads to accumulation of intermediates and hemolysis
 Causes basophilic stippling
 Lead poisoning also causes this
o Methemoglobinemia and cytochrome b5 reductase
 Hb can only bind O2 when Iron is Fe2+ (ferrous)
 Methemoglobinemia is when Iron is Fe3+ (ferric)
 High concentrations (>30%) cause hemolysis due to Hb ppt
 Can cause hypoxia at tissues
 Cytochrome b5 reductase transfers e- to to metHb to → Hb
 Causes of methemoglobinemia
 Ingestions of large amounts of oxidants
 Newborn exposure before reducing capacity is developed
 Tx
 Methylene blue, which carries e- from NADPH, and can then
donate it to metHb
 Hereditary MetHb
 Deficiency in Cytochrome b5 reductase gene (homozygosity)
 Abnormal Hb (HbM), with an AA sub in either the α or β chain
o Homozygous HbM is lethal
Lecture 5: Immune Mediated Hemolytic Anemia and Thrombocytopenia

WAIHA
o IgG to an Rh Ag @ 37° C
 RBC with Abs encounters Fc receptor on macrophages in the spleen
 RBC loses part of its membrane, becomes spherocyte and hemolysis
occurs
o Labs
 Hemolysis
 ↓ haptoglobin
 ↓ Hct
 ↑ Bilirubin
 ↑ LDH
 Spherocytes +/- bite cells
 Coombs test for Ab
o Tx
 Transfusion support
 Suppression of Ab
 Prednisone to ↓ regulate the Fc receptors for the IgG Ab
 IVIG
 Splenectomy

CAIHA
o IgM and complement activation/fixation to RBC surface glycoproteins @ 0-4° C
 Anti-I against adult RBCs
 Anti-I against fetal or cord RBCs
 Activates complement cascade; C3 and C4 are targets for receptor
mediated immune attack; C9 in membrane causes leakiness and lysis
o Chronic
 Older people associated with a B cell neoplasm
o Acute
 Younger after M. pneumoniae or EBV (mononucleosis)
o Sx
 Dyspnea
 Fatigue
 Agglutination/discoloration in the most distal parts of the body
 Weakness, back pain, dark urine upon cold exposure
 Can thrombose in the periphery
o Labs
 + Coombs test using anti-C3 (IgM falls off, but complement stays
attached)
o Tx
 Keep patient warm
 Steroids and splenectomy are not effective

Paroxysmal Cold Hemoglobinuria
o Features of both WAIHA and CAIHA
 IgG that functions in the cold, against P Ag on RBCs
 Fixes complement in the periphery
o Associations
 Congenital or 3° syphilis
 Kids who develop it after a viral infection
o Tx
 Keep patient warm
 Tranfusion
 Prednisone
 Spenectomy not helpful

Drug-related hemolysis
o Methyldopa – direct Ab induction with hemolysis; similar to WAIHA
o Cephalosporins – immune complex deposition on RBC and complement is
activated
o High dose PCG – drug binds to RBC, Ab binds to Ab.
o Tx: Stop drug

Immune Thrombocytic Purpura
o Autoantibodies against one’s own platelet glycoproteins
 Platelets coated with Ab are captured by the Fc receptors on macrophages
in the spleen and liver
o Also, there is an underproduction of platelets
o Kids: suddent onset of petechiae/purpura usually following an infectious illness
o Adults: Variable presentation; mild brusing – overt bleeding; no viral illness;
chronic
o PE: petechiae/purpura; splenomegaly or lymphadenopathy is not typical
o Examination of the peripheral smear is mandatory
 Thrombocytopenia
 Normal platelet size and morphology
 Normal RBC and WBC counts/morphologies
o You should not see these features:
 Giant platelets
 RBC abnormalities
 Leukocytosis/leucopenia
o Tx
 Adults: steroids, IVIG, splenectomy
 Kids: resolve on its own, IVIG
o Pregnancy
 Late in pregnancy, lower platelet count than gestational thrombocytopenia
 IgG antiplatelet Abs can cross the placenta and cause thrombocytopenia in
the infant
Lecture 6: Sickle Cell Disease and other Hemoglobinopathies

Sickle cell disease (phenotype)
o Sickle cell anemia (homozygous HbS)
o HbSC disease (compound heterozygous HbS + HbC)
o HbS-thalassemia (compound heterozygous HbS + one thalassemia gene)

Pathophysiology
o HbS polymerization
 Glu → Val @ B6, which permits HbS to polymerize when it is
deoxygenated
 Reoxygenation melts polymer, but repeated cycles damage the membrane,
releasing radicals and causing them to become sticky.
 The cell also begins to leak water and K+, increasing HbS
concentration and increasing the likelihood of polymerization
 These sticky cells abnormally interact and damage the endothelium
o Membrane damage → ↑ intravascular hemolysis → ↑ Hb in blood → ↓ NO →
vasoconstriction
o ↑ LDH

Clinical
o Painful episode
 Acute excruciating bouts of pain in the chest, abdomen or extremities
 Require opioids
 Vasoocclusive
o Acute Chest Syndrome and Pulmonary HTN
 Acute chest syndrome ↑ with vasoocclusion
 Postoperatively
 Fever, chest pain, cough, lung infiltrates and hypoxemia
 Chlamydia
 Blood transfusion when hypoxia occurs or the infiltrates advance
 Pulmonary HTN ↑ with hemolysis
 May or may not result from acute chest syndrome
o Osteonecrosis (aseptic necrosis of bone)
 ↑ with vasoocclusion
 Heads of femur, humerus
 Pain, loss of function, hip/shoulder replacement
o Stroke
 Occlusion of large intracranial vessels
o Others
 Renal failure

Labs
o Blood counts/smears
o DNA-based Dx

Tx
o Transfusion when:
 blood pooling in spleen and hypovolemic shock
 B19 parvovirus suspending erythropoiesis causing an aplastic crisis
 severe acute chest syndrome
 Chronic transfusions to reduce risk of stroke
 require Iron chelation
o Pain alleviation by opioids (not prn)
o ↑ HbF with hydroxyurea
 HbF inhibits HbS polymerization
o Stem cell transplantation – kids

HbC, HbE
o β-globin gene mutations
o HbC only problematic when with HbS
o HbE only when with β-thalassemia
Lecture 7: The Thalassemias

Mutation in the globin gene that leads to decreased or absent globin chain production
o Can occur in any of the globin genes, α, adult β, the fetal γ, or the adult δ
o α and β are the most common and important
o Malaria resistance

α-Thalassemias
o The α gene cluster is on C16p and is made up of 1 embryonic ζ and 2 α-globin
genes (a total of 4 functional genes)
 These are expressed throughout fetal and adult life
o The common mutations are deletions
o Silent Carrier
 Deletion/mutation involving only 1 gene; clinically well
 Normal Hb, normal MCV
o Trait
 Deletion/mutation involving 2 genes, either in tandem or one on each
chromosome; clinically well
 Normal Hb, microcytosis (ddx: iron deficient anemia)
 If in tandem + partner with similar change = 25% risk for Hb Barts
hydrops fetalis
o HbH Disease
 Deletion/mutation in 3 genes, leading to only 1 normal gene
 Leads to excess of β-globin genes, which form tetramers called HbH
 Moderate anemia
 Marked microcytosis
 25% risk in each pregnancy for Hb Barts hydrops fetalis
o Hb Barts hydrops fetalis
 Lacks all α-globin genes
 Fetuses are severely anemic and usually die in the 2nd trimester or within
hours after birth
 Mom at risk for pre-exclampsia, HTN, hemorrhage, dystocia (difficult
delivery)
o Labs
 Microcytosis
 Normal ferritin
 Normal HbA2 (no β-thalassemia trait)
o Tx
 HbH disease: preventive and supportive
 Avoid oxidant drugs
 Promptly treat infections and other febrile illnesses

β-thalassemias
o The β-globin gene cluster is on C11p
o γ-globin genes are expressed in utero, and switches to β slowly
 β-globin gene mutations would not interfere with fetal development in
utero; their effects usually manifest 6 months after birth
o Most mutations are point mutations, deletions are rare
o β-thalassemia minor (trait)
 Heterozygous, clinically well
 Microcytosis, borderline low Hb
o β-thalassemia major
 Homozygous or compound heterozygous for β-thalassemia mutations
 Severe anemia, require monthly transfusions
o β-thalassemia intermedia
 Anemic
 Clinical severity somewhere in-between minor and major
o Pathophysiology of thalassemia
 Imbalance of α and β globin genes, leading to excess of the normally
produced one
 Excess α will form tetramers, damage RBC membranes, cause hemolysis,
ineffective erythropoiesis, iron overload, splenomegaly, marrow
hyperplasia and osteopenia
o Lab Dx
 Microcytosis, regardless of the Hb level is the most important
 β-thalassemia
 ↓ MCV
 NL ferritin
 ↑ HbA2
 Major
o Severe anemia
o Marked microcytosis
o Anisocytosis (variable RBC size)
o Poikilocytosis (abnormal RBC morphology)
o Polychromasia (variable Hb content)
o Erythroblastosis (blasts in blood)
o ↑ HbF
o Tx



Monthly transfusion in β major
 Iron overload (cardiac disease), chelation
Marrow transplant
Hydroxyurea to ↑ HbF
Lecture 8: Lymphoma and Lymphoproliferative Disorders


Neoplastic transformation of lymphoid cells → malignant lymphomas
o Hodgkin’s
 Reed-Sternberg cell
 Bi-nucleate cell in inflammatory background
o Non-Hodgkin’s
B cell lymphomas represent clonal expansions of discrete stages of differentiation of the
cell as it progresses from a small round regular B cell to a plasma cell
o 80-85% of malignant lymphomas are B cell, the rest are T cell
Lecture 9: Hodgkin’s Disease and Non-Hodgkin’s Lymphoma


Malignancy of lymphocytes; reside in lymphoid organs rather than in the circulation
Most lymphadenopathy is not malignant
o Infections
o Auto-immune
o Immunodeficiency
o Drugs

Origin
o Lymphocytes derive from pluripotential hematopoietic precursors (splits off from
myeloid and erythoid precursors early on)
 CD20 and CD19 are on the major stages of B cells in lymphomas
o B cells start in the bone marrow → lymph node/spleen and mature in response to
cytokines and Ags binding to their surface Ig
 Heavy chain → isotype (IgM, IgG, etc.)
 Variable regions of heavy and light chains → Ag binding site
 DNA → somatic rearrangements
o T cells start in the bone marrow → thymus → education (delete self-reactive
clones and expand those that react correctly with self-MHCs)
 Reponsive to cytokines and engagement of TCRs

Clinical
o Lymphadenopathy
 Painless, rubbery, chronic
 >1 cm are suspicious
o +/- hepatosplenomegaly
o B symptoms (fever, 10% weight loss, night sweats)

Dx and staging
o Dx requires histological analysis (biopsy)
o Staging requires CT or MRI, plus LP to determine CNS involvememt (if CN
signs)
o CBC, +/- ↑ LDH (lymphocyte turnover), +/- ↑ LFT (liver involvement)

Hodgkin’s vs. Non-Hodgkin’s (quickly)
o Hodgkin’s
 Reed-Sternberg cell
 Pleiomorphic cellular infiltrate (variable in size/shape)
 Usually includes T cells and eosinophils
 +/- fibrosis
 ↑ with EBV?
 Cell of origin probably B cells
 Excellent cure rate
o Non-Hodgkin’s
 Monomorphic lymphoid infiltrate of B or T cells (85% B cells)


 Clonal lymphocytes
 DDx from reactive lymphocytosis
↑ with age
OK cure rate

Non-Hodgkin’s Pathogenesis
o Lymphocytes have ↑ somatic mutation → ↑ likelihood of other chromosomal
rearrangements; can confer a growth advantage → malignancy
o Burkitt’s Lymphoma (activation of TFs)
 t(8;14) translocation
 Ig heavy chain promoter fused to myc gene → myc overexpression
o myc = TF that controls cell growth
o Mantle cell Lymphoma (activation of cell cycle machinery)
 t(11;14) translocation
 Ig fused to cyclin D1 → cyclin D1 overexpression
o Cyclin D1 can rush cells through the cell cycle
 Hard to Tx – resist apoptosis induced by CT or RT
o Over-expression of anti-apoptosis genes
 t(14;18) translocation
 Fuses the IgH promoter to bcl-2, an anti-apoptosis gene
o Li-Fraumeni Syndrome (p53 mutation)
 Homozygous -/- for p53 (usually one familial + one acquired) → familial
cancers at a young age
o Other things
 Environment
 Pesticides, Pollutants, Viruses (EBV, HTLV-1, HHV-8)
 Immunosuppresants + EBV → polyclonal lymphoproliferative disorder →
can rapidly evolve to monoclonal B cell lymphoma

Hodgkin’s Pathogenesis
o Infectious? (↑ in 3rd decade and the elderly; ↑ in Northern climates; ↑ in first bornchildren)
o Binucleate Reed-Sternberg cell
 Clonally rearranged Ig genes, but does not express CD19 or CD20
o Pleiomorphic infiltrate of reactive T cells, eosinophils recruited by tumor cells →
cytokines

Ann Arbor staging of Hodgkin’s Lymphoma
o I = one lymph node group
 90% young people cured; radiation
o II = two or more lymph node group on same side of the diaphragm
 90% young people cured; radiation
o III = both sides of diaphragm
 Chemo
o IV = disseminated or visceral disease
 Chemo

Revised European-American Lymphoma classification of non-Hodgkin’s lymphoma
o Low Grade
 Incurable with standard Tx; (t(14;18) translocation makes it hard for
CT/RT to work)
o Intermediate Grade
 Potential to be cured; CT
o High Grade
 Burkitt’s (myc overexpression) is rapidly fatal; can be cured
Lecture 10: B Cell Chronic Lymphocytic Leukemia



B-CLL is the most common type of leukemia
Dx
o Lymphocytosis
o Bone marrow involvement of >30%
o <55% atypical/immature lymphoid cells in peripheral blood
o Low density of surface IgM or IgG with clonal expansion of κ or λ light chains
o Characteristic CD5+ CD19+ CD23+ CD10 CD5 is usually on T cells
DDx
o AML – Blasts
o CML – Full spectrum of myeloid development
o ALL – Blasts
o Hairy cell Leukemia – B cell malignancy with CD5- CD20+ CD11c+ CD103+

CLL Pathophysiology
o Disease of small, round, mature B cells; cannot be distinguished from normal
lymphocytes on peripheral smear
o Distinctive CD5+ CD19+ CD23+ CD10o Monoclonal light chain (κ or λ)
 Benign lymphocytosis is polyclonal that expresses both κ and λ
o Variable molecular basis
 Deletions at 13q14 is the most common event

Prognosis
o Varies from months → decades
o Rai Stage
 Stage 0 (only lymphocytosis) → good survival
 + anemia, thrombocytopenia, lymphadenopathy, hepatosplenomegaly →
worse survival
o ↑ somatic hypermutation of Ig variable region → good prognosis
o Short lymphocyte doubling time → worse prognosis
o If the only change is a deletion at 13q14 → good prognosis
o CD38 expression → poor prognosis
o ZAP-70 (Tyr kinase)

Disease Complications
o Infections are the leading cause of death (prophylaxis)
o Autoimmune disease (causes 14% of WAIHA), but not those Igs produced by the
clone itself – polyclonal and derived from other cells
o Richter’s Syndrome – 2° more aggressive lymphoid malignancy
 ↑ LDH, fever, wt loss, lymphadenopathy
 Med survival = 8 months; resistant to Tx

Tx
o Some patients never require Tx
o Alkylators (cyclophosphamide, chlorambucil)
o Adenosine analogs (Fludarabine) [in combination with alkylators]
 Highly toxic to T cells; contributes to immunodeficiency
o Antibody therapy in combination with glucocorticoids
 Control autoimmune manifestations
o Marrow transplantation
 Risk of GVHD
Lecture 11: Myeloproliferative Disorders

First question in proliferative disorders
o Primary
 Polycythemia Vera
 Essential Thrombocytosis
 CML
 Myelofibrosis with myeloid metaplasia
o Secondary (reactive)
 Tissue hypoxia
 Inappropriate erythropoietin

Polycythemia Vera
o Clonal Disorder
o 90% have mutations in JAK2 → ↑ Tyr kinase → ↑ proliferation
o Clinical (benign if controlled with Tx)
 Hyperviscosity
 Hemorrhage
 Thrombosis
 Pruritis, especially after bathing
 Wt loss
 Splenomegaly
 Gout
 Peptic ulceration
 Fe deficiency
o Lab
 ↑ RBC mass
 Thrombocytosis
 ↑ Histamine
 ↑ serum B12
 Panhyperplasia in the marrow
 ↓ serum Fe
o Tx
 Phlebotomy
 Chemo

Essential thrombocytosis (clonal stem cell disorder)
o Platelet count > 600,000/μL
o No known reactive cause (e.g.: Fe deficiency, chronic inflammation/infection,
drugs, asplenic states, malignancy, hemorrhage, exercise, chronic hemolysis)
o Normal RBC mass
o Stainable Fe in the marrow
o Absence of the Philadelphia chromosome
o 50% have mutations in JAK2 → ↑ Tyr kinase → ↑ proliferation
o Clinical
 >50% asymptomatic




o Lab






o Tx



Hemorrhage
Thrombosis (not associated with platelet count or function)
Splenomegaly
Spontaneous abortions
Platelet count > 600,000/μL
Large platelets
Abnormally clustered megakaryocytes in the marrow
↑ LDH
↓ ESR
↓ CRP
None if asymptomatic
If Hx of thrombosis, ↑ CV risk factors, pre-operative
Chronic Myeloid Leukemia
o Stem cell disorder
o All myeloid elements involved (+/- B cell involvement)
o Philadelphia chromosome +
 t(9:22) translocation
 Bcr/abl
 ↑ Tyr kinase activity → ↑ proliferation
o Without Tx, it will → acute leukemia → death
o Average age = 45 years; younger than Phil- MPDs
o Clinical
 Stable
 Asymptomatic or B symptoms
 Accelerated Phase
 Clinical
o B symptoms
o Splenomegaly
o Bone pain
 Lab
o Anemia
o Thrombocytopenia
o Left shift
o ↑ blasts
o Marrow fibrosis
 Blast crisis
 Blasts > 20%
o Tx
 Bone marrow allo-transplant
 Risk of GVHD
 Tyr kinase inhibitor
 Chemo
 Interferon

Myelofibrosis with Myeloid Metaplasia
o Chronic MPD
 Extramedullary hematopoiesis
 Hepatosplenomegaly
 Hepatic HTN
 Leukoerythroblasic smear
 Nucleated RBCs
 Polychromatophilia
 Teardrop cells
 Early WBC forms
 Marrow
 Dry tap; ↑ fibrosis replacing hematopoiesis
o DDx
 “Burned out” P-vera or ET
 CML
 Metastatic solid tumors
 Granulomatous disease
 Hairy cell leukemia
o Clinical
 Hemorrhage
 Thrombosis
 Abdominal pain/distension from organomegaly and ascites
o Tx
 Chemo
 Thalidomide
 Splenectomy
 Supportive
Lecture 12: Acute Myelogenous Leukemia





Abnormal maturation arrest → accumulation of immature cells
Myeloid progenitors can become:
o Granulocytes
o Erythrocytes
o Monocytes
o Platelets
o Macrophages
Eitiology
o Unclear
o Environmental toxins (radiation, benzene)
o Down’s syndrome
o Fanconi’s Anemia
o 2° leukemia after Tx with an alkylating agent for an unrelated malignancy
o After Tx with topoisomerase II inhibitors
Clinical
o Older people
o Bleeding
o Bruising
o Infection
o Fatigue
o Organ dysfunction 2° to leukostasis
 Difficulty thinking
 Blurry vision
 Chest pain
 SOB
 Kidney/liver failure
o DIC
o Tumor lysis
 ↑ WBC count → begin Tx → WBC lysis → cellular contents release →
acidosis, renal failure 2° to urate deposition, hyperphosphatemia,
hypocalcemia
Lab/Dx
o Anemia
o Thrombocytopenia
o ↑ or ↓ WBC count
 If markedly ↑, leukostasis → organ dysfunction
o Marrow
 Hypercellular
 ↓ differentiation
o Myeloid leukemic blasts in periphery/marrow
 ↑ nuclear/cytoplasmic ratio
 ↑ nucleoli
 Auer rods (immature granules)


Pathogenesis
o Tranlocations t(8:21); inv 16 and t(15;17) are the most common
o >50% of AML cases involve a chromosomal rearrangement
Tx
o Induction chemo
o Risks
 Cytopenia → ↑ infections
 Tumor lysis
o Older patients
 Poor performance
 Poor candidates for induction chemo
 Case-by-case; need more Tx for the elderly
Lecture 13: Acute Lymphoblastic Leukemia







Most common leukemia in children
o ↑ in boys
Also found in adults, but they respond less well to Tx
Can relapse to CNS, testes
Clinical
o Bone pain (limping, inability to bear weight)
o Headache
o Lymphadenopathy/mediastinal mass
o Testicular enlargement
o Pancytopenia
Evaluation
o Marrow biopsy and aspirate
o CBC
o Serum electrolytes
o Urate, LDH, renal function
o Lumbar puncture
o Immunophenotyping (necessary)
 TDT+ (precursor B cell) is the most common type
 Immature lymphocytes with 1-2 nucleoli
 ↑ nucleus/cytoplasm ratio
Prognosis
o < 50,000 good
o < 2 years old or >10 years old worse prognosis
o Old age worse
o Females better
o Absence of CNS disease good
o Precursor B cell ALL better than mature B or T cell ALL
o Hyperdiploidy (>50 chromosomes) better
o Philadelphia chromosome+ (t(9;22)) worse
Tx
o Induction chemo
o Kids with Philadelphia chromosome+: allogenic marrow transplantation
o Adults: allogenic marrow transplantation
Lecture 14: Multiple Myeloma







Accumulation of neoplastic plasma cells in the marrow
Cells produce large amounts of Ig that can be detected in the serum and/or urine
o Reciprocal ↓ of other Ig
↑ osteoclast activity 2° to ↑ expression of cytokines → osteolytic lesions
Multiple Myeloma is incurable with current standard chemo
Complications (from mass effects, cytokines or protein deposition)
o Anemia
o Osteopenia
o Renal failure
o Hypercalcemia
o Immunodeficiency
Dx
o Monoclonal plasma cells in the marrow or other sites
o Monoclonal Ig in the serum and/or urine
o Bone involvement
Clinical
o Non-specific
o Paraprotein (↑ plasma volume, ↓ anion gap [2° to ↑ +M Protein],
pseudohyponatremia or pseudohypoglycemia 2° to ↑ water in serum)
o Hypercalcemia (mediated by osteoclast activating factor)
o Hematologic
 Rouleaux on smear (roll of coin – pseudomacrocytosis)
 Anemia
 Thrombocytopenia
 M protein coats platelets → dysfunction
o Renal insufficiency
 Light chain deposition → tubular dysfunction
 Cast nephropathy (light chain ppt, ↓ GFR)
 Nephrotoxic Abs
o Immunodeficiency
 Effective hypogammaglobulinemia
 ↓ T and B cell proliferation
 ↑ infections
o Skeletal
 Punched out bone lesions
 ↑ fractures
o Neurologica
 Cord compression
 Neuropathy

Tx
o Standard
 Melphalan
 Prednisone
o Complete remissions in ≤ 5%
o Interferon
o Erythropoetin
 Improve associated anemia
o Novel therapies
 Thalidomide
 Create a hostile environment that ↓ the growth of myeloma cells
 ∆ adhesions molecules and interactions between tumor cells and
marrow stromal cells
 Velcade (Bortezomib)
 Proteosome inhibitor
 ↓ growth
 ↑ apoptosis
 Overcomes drug resistance
 Lenalidomide (Revlimid)
 Analogue of thalidomide

Related disorders
o Monoclonal Gammopathy of Unknown Significance (MGUS)
 Serum monoclonal protein (M protwin, IgA, IgG or IgM) at a
concentration ≤ 3 g/dL
 < 10% plasma cells in the marrow
 No bone lesions, anemia, hypercalcemia or renal insuffiencicy
 In other words, no organ damage
 ↑ multiple myeloma development later
 No evidence for a neoplastic plasma cell proliferative disorder or a B cell
lymphoproliferative disorder
 Asymptomatic

The major concern of MGUS is the risk of → symptomatic plasma cell
proliferative disorder
 IgG or IgA MGUS → MM, AL amyloidosis, etc.
 IgM MGUS → lymphoproliferative disorder (non-Hodgkin’s,
CLL, etc.)
o AL Amyloidosis
 β-pleated sheet, Congo red dye, apple green birefringence
 AL = light chain deposition
 Non-specific symptoms (weight loss, fatigue, swelling, bleeding, SOB)
 ↑ involvement of kidneys and heart
 Nephrotic syndrome
 Restrictive cardiomyopathy → rapidly progressive heart failure


Hepatomegaly, macroglossia, carpal tunnel, etc.
Tx: supportive (diuretics, defibrillation, etc.), ↓ underlying plasma cell
dyscrasia
o Waldenstrom’s Macroglobulinemia
 Proliferation of intermediate cells between B cells and plasma cells
 Lymphoplasmacytic infiltrate of the marrow
 Lymphadenopathy
 Anemia
 Neuropathy
 Organomegaly
 IgM gammopathy
 Hyperviscosity syndrome
o IgM (pentamer) → blurred vision, fatigue, mucosal
bleeding, headache, ∆ mentation
o Tx: plasma exchange
 Tx: alkylating agents (chlorambucil), monoclonal Ab to CD20
(rituximab), nucleoside analogues (fludarabine, cladribine)
Lecture 15: Coagulopathies

Normal hemostasis
o Vascular injury → platelets exposed to subendothelial collagen → 1° plug
formation
o Reinforced by activation of coagulation and fibrin formation → 2° hemostatic
plug
o Platelet reactions
 Adhesion to subendothelial collagen
 Glycoprotein Ib (platelet receptor)
 vonWillebrand’s factor
o Produced in endothelial cells under autosomal genetic
control
o Layered on subendothelial collagen
o Bridges platelets and collagen, platelet adhestion
o Binds and stabilizes inactive factor VIII)
 Activation
 Shape change (2b3a receptor forms, binds fibrinogen and forms platelet
aggregates)
 Secretion
 Depends on
o Arachidonate
o Thromboxane A2
o Calcium mobilization
 Aggregation
o Coagulation cascade
o Coagulation Inhibitors
 Antithrombin → ↓ Xa and many others
 Heparin ↑ AT binding to Xa 1000x
 Protein C → ↓ Va and VIIIa
 Protein S is a cofactor
 Tissue Factor Pathway Inhibitor (TFPI) → ↓ Xa, VII
o Dx of coagulation disorders
 Surface bleeds = platelet defects
 Petechiae
 Deep tissue bleeds = coagulation defects
 Ecchymoses
 Coagulation assays
 aPTT = Activated Partial Prothrombin Time
o Remove TF from plasma sample
o Phosopholipid (an activator) and Calcium are added
o Measure time until clot forms
o Tests intrinsic pathway
 PT/INR = Prothrombin Time
o Add TF and Calcium to plasma sample
o Measure time until clot forms
o Tests extrinsic pathway

Hemophilia (congenital)
o ↓ Factor VIII most common (hemophilia A)
 Normal Factor VIII
 Accelerates the rate of X → Xa
 Circulates with vWF
 Under X chromosome control
 Disease



 Normal vWF levels
 X-linked
 Severity α levels of ↓ Factor VIII
Clinical
 Spontaneous bleeding into muscles and joints
o Repeated bleeding → joint damage and akylosis
 Mucous membrane bleeding
o Tooth extractions
o Hematuria
o CNS bleeding rare
 Pain
Dx
 History of a congenital disorder
 Abnormal aPPT (extrinsic)
 Normal PT (intrinsic)
 Normal thrombin time
 ↓ Hb only duing major hemorrhage
 Assay for Factor VIII or IX
Tx
 Plasma concentrates of Factor VIII
o Risk of Hep, AIDS
o Switch to recombinant forms
o Risk of Ab to Factor VIII production
o ↓ Factor IX
 Exact same clinical syndrome as ↓ Factor VIII
 Usually less severe
 2/3 of cases have an absolute reduction of factor IX, rather than a reduced
functionality
 X-linked disease

Von Willebrand’s disease (congenital)
o ↓ vWF activity and 2° ↓ Factor VIII (→ ↑ aPPT)
o Autosomal disorder with variable penetrance → ↓ platelet adhesion
o Platelet disorder → surface bleeds, petechiae
o Dx
 History
 Labs
 Abnormal aPPT
 Abnormal bleeding time
 Normal PT
 Normal thrombin time
 Normal platelet count
o Type I: Absolute reduction in vWF
o Type II: Qualitative defect in the polymerization of vWF subunits and loss of
function
o Tx
 Less intense than for hemophilia
 Concentrates of VIII/vWF for serious bleeding
 DDAVP → ↑ vWF

Vitamin K Deficiency (acquired)
o ↑ in post-op states with poor nutrition and antibiotics
o ↑ PT 2° to ↓ VII (shortest ½ life)
 Continues with ↓ IX, X, II
o Tx: IV or PO Vit K

Liver Disease (acquired)
o ↑ PT 2° to ↓ VII (shortest ½ life) [prognostic value]
o ↓ fibrinogen is a poor prognostic sign
o Biliary tract disease → coagulopathy 1/α to Vit-K dependent factors levels
 Results from impaired Vit K absorption
o Portal HTN → hypersplenism → thrombocytopenia
o Can cause ↓ or dysfunctional factor synthesis

Disseminated Intravascular Coagulation (DIC)
o Diffuse hemorrhagic disorder
o Pathologic activation of coagulation by some underlying disease
o Fibrin clots form → 2° fibrinolysis → ↑ consumption of coagulation factors,
platelets, RBCs
 Factor deficiency (I, II, V, VII, XIII)
 Thrombocytopenia
 Excessive fibrinolysis
 ↑ FDP
o Diffuse superficial hemorrhage
 Ecchymoses
 Petechiae
 Oozing from mucous membranes
o Dx
 Variable clinical manifestations
 IV or SubQ heparin can interrupt the process of factor consumption

Other things
o Nephrotic syndrome → loss of coagulation factors
o Massive blood transfusion → dilution of coagulation factors
o Antibodies to coagulation factors or phospholipids (lupus)
o Drugs
Lecture 16: Thrombotic Disorders and Their Treatment




Arterial thrombosis: Hypercoaguable state → atherosclerosis → ↑ shear stress →
↑ platelet activation
o White thrombus (platelet rich)
Venous thrombosis: Stasis → clotting factors interact → clotting cascade activation
o Red thrombus (RBC rich)
Tx
o Arterial
 Inhibit Thromboxane (NSAIDS, ASA)
 Inhibit ADP (Clopidogrel)
 Gp Ib-IX and GP IIb-IIIa receptor antagonists
o Venous
 Heparin
o Both
 Prevention
 Warfarin
Hypercoagulable states
o Antithrombin Deficiency (Autosomal dominant)
 Most severe form of inherited hypercoagulable states
 Antithrombin forms a complex with thrombin and prevents the activation
of fibrinogen (↑ in the presence of heparin)
 Tx: Heparin, warfarin
o Protein C Deficiency (Autosomal dominant)
 Protein C is a Vit K dependent protein; activated by thrombin
 Inhibits factors Va and VIIIa
 Tx: Warfarin
 ↑ warfarin induced skin necrosis
o Protein S Deficiency (Autosomal dominant)
 Protein S is a Vit K dependent protein; cofactor to Protein C
 Tx: Warfarin
 ↑ warfarin induced skin necrosis
o Activated Protein C Resistance (Arg506 → Gln)
 AA substitution on Factor Va (Factor VLeidin)
 This Va is resistant to Protein C
 Tx: Heparin followed by Warfarin
o Prothrombin Gene Mutation (G20210A)
 ↑ prothrombin activity → venous thrombosis
o Dysfibrinogenemias
 Fibrinogen resistant to plasmin digestion
o Homocysteine
 ↑ atherosclerosis, thrombosis 2° to endothelial cell damage
 Tx: folate
Lecture 17: Platelet Disorders

Thrombotic Thrombocytopenia Purpura
o Immune-mediated platelet destruction
o ↑ aggregation of platelets, coagulation
o Since ↓ platelets available, ↑ purpura
o Sx
 Thrombocytopenia
 Hemolytic anemia
 Renal failure
 Normal PT, aPPT (unlike DIC)